Hand Tumours

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Hand Tumours

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Most common hand tumours

• 95 hand tumours comprised of
• Ganglion
• Giant Cell Tumour of tendon sheath
• Epidermoid Inclusion Cysts
• Haemangioma
• Lipoma
• Other tumours arise from bone cartilage,
  muscle, nerve, skin adnexae, subcutaneous
  tissue, tendon and synovium, vessel

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Mankins Hand Tumour Axioms

• Primary bone tumours are usually benign
• The most common bone tumours are enchondroma and
  osteocartilaginous exostosis, except in distal
  phalanx which is epidermal inclusion cyst
• Deep soft tissue tumours (other than ganglion,
  lipoma, GCT) are often malignant
• Epithelioid sarcoma, synovial sarcoma and clear
  cell sarcoma are common malignancies in
  hand/forearm. They are highly malignant and may
  metastasize to lymph nodes
• Synovial chrondromatosis, synovial sarcoma and
  liposarcoma may show calcification on radiology
• Metastatic carcinoma, except lung, lymphoma and
  myeloma are rarely seen in the hand

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History

• Age
• Duration
• Pain
• Neurological effects
• Nature of onset
• Variation in size
• Previous similar swellings
• Similar swellings elsewhere
• Symptoms related to other sites

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Examination S3, C2, M (NI)

• Size
• Site
• Shape
• Colour
• Consistency
• Mobility
• Nodes
• Imaging

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Investigations

• Plain Xray
• Calcification
• Anatomical location
• Changes in bony architecture
• Response of host bone
• Internal contents
• Xeroradiography
• Bone scans, CT, MRI, Angiogram
• CXR
• FBC, EUC, U/A
• Also ESR, BSL, CMP, LFT, TFT, PTH

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Ennekings staging
Surgical Grade Anatomical location Metastases
G0 Benign T1 Intra-compartmental M0 No mets
G1 Low Grade T2 Extra-compartmental M1 Metastases
G2 High Grade

• Criteria for G2
• Pain rapid growth
• Marked destruction on Xray
• Extensive uptake on bone scan
• Cortical disruption on CT
• Satellite lesions on MRI
• Biopsy frequent mitoses, cellular atypia, poor
  differentiation and necrosis
• Compartments (T grade)
• Intraosseous
• Paraosseous
• Intra articular
• Intra muscular
• Some locations are not compartmentalised, so T2
  by definition
• Vascular plane
• Mid hand
• Antecubital fossa
• Axilla

T1 T2
G1 IA IB
G2 IIA IIB
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Ganglion

• Most common mass in the hand (50-70)
• Probably arise from myxoid degeneration of
  collagen
• Lined with flattened mesothelium, not synovium,
  not secretory cells
• Can be found in association with any synovial
  lined cavity, but unlikely to be true synovial
  hernia
• 4 common sites
• Dorsal wrist ganglia are the most common type of
  ganglion (60-70), associated with scapholunate
  ligament
• Volar wrist ganglion, may be associated with
  multiple ligaments
• Proximal digital crease, associated with A1/A2
  pulley
• Distal interphalangeal joint
• 30-40 spontaneously resolve within the first year

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Giant cell tumour of flexor sheath

• Second most common swelling in hand
• Arises in presence of synovial tissue (flexor
  sheath, IPJs)
• Usually asymptomatic
• Characteristic yellow brown colour from
  haemosiderin
• High recurrence rate due to perforations in
  macroscopic capsule
• Recurrence rates associated with multiple
  lesions, thumb lesions, presence of bony erosion,
  nm23 gene

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Inclusion cyst

• Minor skin wound drives basal skin cells beneath
  skin surface
• Forms smooth, spherical tumour attached to skin
  but mobile over deep structures
• Almost exclusively palmar surface, most common
  around fingertips and amputation stumps
• Smooth lytic lesion, no calcification, mildly
  expansile, marginal sclerosis, cortex intact, no
  periosteal reaction

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Glomus tumour

• Benign growth of cells of normal glomus
  apparatus, an a-v anastomosis in dermis used to
  control skin circulation
• Essentially a hamartoma
• Triad of symptoms paroxysmal pain, pin point
  tenderness (Loves test) and temperature
  sensitivity to cold
• Usually solitary, most commonly subungal
• Presents due to symptoms rather than mass
• Can precipitate pain with ethyl chloride spray
• If found can be seen as a small purplish patch
• MRI can detect 5mm lesions, U/S 2mm

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Enchondroma

• 90 bone tumours of hand
• 35 enchondromas occur in hand
• Benign hyaline cartilaginous growth within
  medullary cavity
• Peaks in 3rd and 4th decades, MF
• May degenerate into chondrosarcoma (lt1) heralded
  by unremitting pain, rapid growth and cortical
  disruption
• Painless swelling, often incidental finding or
  pathological fracture
• Central, usually in tubular bones, lytic with
  calcifications, expansile, margins well defined,
  cortex intact but often very thin
• Multiple enchondromatosis is found in Olliers
  disease and Maffuci syndrome
• Rate of malignant degeneration is much higher,
  30 in Olliers and up to 100 in Maffuci

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Chondrosarcoma

• Most common malignant primary bone tumour in hand
  (60), but still rare hand swelling
• 25 arise secondary to degenerative change of
  multiple enchondromatosis
• Peak incidence in 7th 8th decades
• Pain
• Lies in subchondral bone, epiphyseal equivalent
  of tubular bones
• Central, scattered lysis with punctate
  calcifications, no expansile, no marginal
  sclerosis, late cortical disruption
• Associated soft tissue shadow with radiating
  spicules (flattened at ends unlike osteosarcoma),
  Codmans triangle
• Requires wide margins, no role for radiotherapy
  or chemotherapy
• Histopath can be difficult
• 5 year survival 70, 10 year survival 60-70

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Osteosarcoma

• Heterogenous group of malignant neoplasms
• Primary osteosarcoma peaks in 10-25yo, secondary
  (to Pagets, radiation etc) peaks in 5th 6th
  decades
• Aching, constant pain, worse at night
• Metaphyseal, destructive lytic lesion associated
  with widely variable amount of new bone formation
• Cortical disruption, spiculation, Codmans
  triangle
• Skip lesions and metastases
• Bone scan MRI to define lesion and skip lesions
• Staging Chest CT, and staging biopsy advisable
• Poor prognosis, dependent on duration, location
  (proximal worse), size, histological grade and
  presence of metastases
• 10 year survival up to 70

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Rhabdomyosarcoma

• Embryonal form peaks in infancy, adult form peaks
  in young adults
• Actively growing soft tissue masses
• Routine Xrays show spread to bone, but better
  assessed by bone scan
• MRI and angiogram are important investigations
• Radical extracompartmental excision
• Later generations of chemotherapy and
  radiotherapy may allow some limb sparing
• 5 year survival 50 embryonal, 30 adult

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Giant cell tumour of bone

• Occurs in skeletally mature, peak incidence in
  3rd 4th decades, F 57
• 2 GCT bone occur in hand, most commonly distal
  phalanx
• Intermittent pain and local swelling
• Epiphyseal equivalent, eccentric
• Central radiolucency, fine trabeculation,
  expansile, no marginal sclerosis, cortical
  erosion, soft tissue extension in later or more
  aggressive tumours
• Multiple GCT common, need bone scan to locate
• May develop secondary aneurysmal bone cysts
• 80 recurrence rate in hands (1/3 cured after 1
  treatment, 1/3 after 2, 1/3 need gt 2 treatments)